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Inspection visit

Follow-up on corrections

NIR COMMUNITY IIILicense 3746042646 citations on this visit
6 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Deficiencies visit. LPA identified herself and was allowed entry into the facility by Staff, Conchita Gallardo. LPA discussed the purpose of the visit with staff present. Administrator, Faria Huq and Licensee, Rana Huq arrived during the visit. During a complaint investigation, it was discovered the licensee did not submit an incident report involving Resident #1 (R1). On 10/29/25, R1 wandered away from the facility and staff were not aware. R1's Physician's Report dated 05/08/2023 indicated R1 was ambulatory, and had a diagnosis of a Major Neurocognitive disorder. It also indicated R1 was unable to leave the facility unassisted. The licensee failed to report the incident. Today, LPA observed the following deficiencies: A padlock on the front door and a locking device on R1's sliding door exit located in their room. Staff explained R1 wanders, therefore, the locks were put in place to prevent R1 from wandering from the facility; Cough syrup was on the kitchen counter, accessible to residents; A new laundry room was built but the lock was inoperable and could not be locked, which made cleaning supplies and items that pose a danger accessible; Sharp tools were observed in the backyard; The resident's files did not contain Absentee Notifications; and medical assessments were not within a year for R1 and Resident #2, as the reports were issued in 2023. In addition, the licensee made alterations to the facility. Licensee stated licensing was not notified of the alterations to the facility because a permit was not required by the City to add a wall, which was added for the new laundry room. Continued on LIC 809C. While at the facility, the licensee emailed LPA proof of permit for the Additional Dwelling Unit (ADU), along with an updated LIC 999 Facility Sketch to identify the new additions. The administrator explained the ADU has renters that have no access to the facility or residents. During the visit, R1 attempted to exit the facility unassisted through their sliding door located in their room. Staff was able to immediately redirect R1. Licensee and administrator were made aware of the exit seeking behavior. They were also notified awake staff was required for wandering residents. They ensured R1's needs will be met. Deficiencies were observed and cited along with a civil penalty for a fire clearance violation. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Staff, Milagros Galvan whose signature below confirms receipt of these rights.

Citations

7 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.312(d)Type A

    Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interviews, the licensee did not know the whereabouts of 1 out of 4 [R1] residents, which posed an immediate health and safety risk to residents in care.

  • 1569.317Type B

    Absentee notification plan for missing residents. Every residential care facility...resident is missing from the facility...plan shall include...administrator...inform authorized representative...notify local law enforcement...is missing from the facility. This requirement is not met as evidenced by:Based on interviews and record review, the licensee did not ensure 4 out of 4 [R1-R4] residents had an absentee notification in their written record of care, which posed a potential health and safety risk to residents in care.

  • 87202(a)Type A

    Maintain fire clearance before retaining specified persons

    Fire Clearance. All facilities shall maintain a fire clearance approved by the city...or the State Fire Marshal. Prior to accepting or retaining...obtain an appropriate fire clearance...or the State Fire Marshal. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with their fire clearance, by using a padlock to lock the front door, enabling residents to exit for 4 out of 4 [R1-R4] residents, which posed an immediate health, safety and personal rights risk to residents in care.

  • 87211(a)(1)Type B

    Report specified resident events within seven days

    Reporting Requirements. A written report shall be submitted to the licensing agency...of any of the events specified in (A) through (D) below. This report shall include...date and nature of event...findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not report an incident for 1 out of 4 [R1] residents, which posed a potential health and safety risk to residents in care.

  • 87309(a)Type A

    Ensure hazardous items are locked and not unattended

    Storage Space and Access. Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...tools, sharp objects...are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:Based on observations, the licensee did not ensure cleaning supplies and tools were inaccessible to 4 out of 4 [R1-R4] residents, which poses an immediate health and safety risk to residents in care.

  • 87463(h)Type B

    Annual routine visit with medical professional

    Reappraisals. The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not obtain an annual routine medical visit for 2 out of 4 [R1-R2] residents in care, which posed a potential health and safety risk to residents in care.

  • 87465(h)(2)Type A

    Store centrally held medications in locked secure place

    Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place that is not accessible... supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observations, the licensee did not centrally store medications making them accessible to 1 out of 4 [R1] residents, which posed an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the November 6, 2025 inspection of NIR COMMUNITY III?

This was an other inspection of NIR COMMUNITY III on November 6, 2025. 6 citations were issued: 3 Type A (serious) and 3 Type B.

Were any citations issued to NIR COMMUNITY III on November 6, 2025?

Yes, 6 citations were issued (3 Type A, 3 Type B). The first citation was for: "Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel indepen..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.